Before your child's first appointment

Health questionnaire for children up to 15

Welcome to Tandarts West, a child-friendly, English-speaking dentist in Rotterdam West. To welcome your child well, we ask you (as parent or guardian) to complete this short health questionnaire (anamnesis). It takes about 4 minutes. Your details are stored securely and GDPR-compliant.

Your child's data is confidential. It is sent over a secure connection and only seen by the treating dentist. Prefer paper? Click "Print or save as PDF".

Child's details

Who is your child? We need this for their patient file.

Child's full name *

Date of birth *

Child's BSN (Dutch social security number) 9 digits, found on your child's ID or residence permit

Address (street + house number + postal code + city)

Child's GP (huisarts)

Child's health insurer

Parent or guardian

Who is filling in this form? We'll send the confirmation to this email address.

Full name *

Relationship to child

Phone number *

Email address *

Your child's medical history

Tick what applies.

Child's medication (name + dosage)

Allergies (medication, latex, food, ...)

Vaccinations on schedule?

Oral habits and diet

Important for prevention advice and treatment planning.

Thumb-sucking or pacifier use Nail-biting Mouth breathing (sleeps with mouth open) Grinds teeth at night Eats sweets regularly between meals Drinks sweet beverages regularly (soda, juice) Brushes at least twice a day Uses fluoride toothpaste Is still helped by a parent with brushing

Dental experience and attitude

So we can prepare well for your child.

First time at the dentist Sits calmly in the chair Is restless or hard to calm Is afraid of the dentist (previous bad experience?) Has needle phobia Has had cavities or fillings before

Previous dentist (name + city)

Date of last check-up (approximate)

What should the dentist definitely know about your child?

I am the parent or legal guardian of the child, have completed this questionnaire truthfully, and give Tandarts West Rotterdam permission to process this data for medical treatment, in accordance with the privacy statement. *